PSEU INCOME PROTECTION PLAN APPLICATION FORM Personal Details Full name Miss
Title
Mr
Mrs
Date of birth
D D M M Y Y
Ms
Address
PPS number
Mobile number
Email address
Employment Details Employer
Department/Unit
Work address
Occupation
Staff number
Employment status
Basic earnings
Permanent
Date:
D D M M Y Y
Temporary
Full time
Part time
(must be working more than 20% of full time hours)
Superannuation scheme member Yes
No
1647 GPE EB PSEU App 05/15
Date joined Public Service Sector
Confirmation of Eligibility for Membership Important Information You should obtain a copy of the Plan booklet and understand how the Income Protection Plan works and the terms and conditions before joining. I confirm that: I am a member of PSEU I am actively at work* on the date of signing declaration * Actively at work means that you: • are working the normal number of hours required by your contract of employment, either at your normal place of business or at a location to which you are required to travel for business • are mentally and physically capable of following the duties of your normal occupation, and • have not received medical advice to refrain from work. Where the requirement to be actively at work refers to a particular day, which is not a working day, you will be considered to be actively at work unless your medical records show that you were suffering from a medical condition which would reasonably have prevented you from working normally. We will consider prearranged absence for statutory leave such as maternity or paternity leave or holiday to be actively at work unless medical records show that on the relevant date you were suffering from a medical condition which would have reasonably been expected to prevent you from working normally. I have read and understood the conditions of membership and I am eligible to join the scheme. Are you joining the Plan within 120 Days of joining service?
Yes
No
If "Yes", please sign the declarations and salary deductions mandate. If "No", please complete the Medical Details section below, and also sign the declarations and salary deductions mandate.
Medical Details
1. Have you been absent from work through illness or injury for more than 10 consecutive days in the last 4 years?
Yes
No
2. Is there any ailment or disease to which you have a tendency, or are you currently taking prescribed drugs, medicines, tablets or other treatment? (Contraception, cold and flu remedies and antihistamine for hayfever need not be disclosed).
Yes
No
3. In the last 5 years, have you consulted a doctor or any other medical professional or been advised to have any operation; x-ray, check-up or any investigation or test or are you intending to do so? (Colds, flu, minor muscle injuries, contraception, routine inoculations, and uncomplicated pregnancy need not be disclosed).
Yes
No
4. Have you ever suffered from or had treatment for: (a) Stress, post-natal depression, anxiety, depression, nervous breakdown, or mental disorder?
Yes
No
Yes
No
5. Have you ever been declined, postponed or accepted on special terms by any insurer for Life, Critical Illness, or Disability Insurance?
Yes
No
6. Do you suffer from any medical condition or physical impairment not already mentioned?
Yes
No
(b) Slipped disc, whiplash, or other neck or back problem?
If you have answered Yes to any of the questions in this section please provide additional information below. Please note that you may be asked to complete a tele-underwriting interview using the mobile number provided above.
1647 GPE EB PSEU App 05/15
Disclosure of material facts: Please note carefully: Failure to disclose all material facts could render your contract void. A material fact is one which an insurer would regard as likely to influence the assessment and acceptance of the proposal for insurance. If you are in doubt as to whether certain facts are material, such facts should be disclosed. Any information not fully dealt with in the answers to the questions should be inserted in the section headed ‘Further Medical Evidence'. Under the provisions of Part 4 of the Disability Act 2005 you should not tell us the results of any genetic test but you should still disclose full details of any non-genetic laboratory test or investigation, symptoms, treatment and family history.
Further Medical Evidence Please use this space to provide any additional information to any question above to which you answered Yes. Please continue on a separate sheet if necessary.
Additional Information General Practitioner’s name General Practitioner’s address
General Practitioner’s telephone number
Fax
Have you changed doctor in the last two years?
Yes No
If Yes, please provide details.
Name and address of your previous General Practitioner
General Practitioner’s telephone number
D D M M Y Y
and
D D M M Y Y Fax
1647 GPE EB PSEU App 05/15
Dates registered between: (dd/mm/yy)
Declaration I declare that I am actively at work today, or capable of being actively at work today. I also declare that the above statements (including any statements written down at my dictation) are TRUE and COMPLETE. I understand that failure to disclose a Material fact may constitute grounds for rejection of a claim. I consent to Generali PanEurope dac (Generali PanEurope) or their agents seeking information from any doctor who at any time has attended me concerning anything which affects my physical or mental health or seeking information from any insurance office to which a proposal has been made for insurance on my life and I authorise the giving of such information. It is agreed that this declaration and any other declaration made in connection with this proposal including statements made to a medical examiner and/or nurse acting on behalf of the tele-underwriting provider acting on behalf of Generali PanEurope dac shall be the basis of the contract of assurance and/or insurance between me and Generali PanEurope dac. It is understood that Generali PanEurope dac must be notified of any other changes in my health and/or circumstances prior to the assumption of risk. I understand that I may be asked to do a telephone interview as part of the process of evaluating my health status for the purposes this application. I understand and consent to the recording of this telephone interview. I understand that the assurance shall not commence until this application has been accepted by Generali PanEurope dac and the first contribution has been paid. I consent to medical information obtained from a medical examination or health screening report being shared with my Doctor. I further consent to Generali PanEurope or its agents accepting medical reports electronically transferred to them from my Doctor and to copies of the reports being electronically transferred to any other company that I have applied to at their written request. Please tick this box if you do not consent to the electronic transfer of medical reports. If your proposal for insurance is declined or accepted on special terms then that will be noted on a registry administered by the Central Bank of Ireland, and may be shared with other companies as a protection against non-disclosure of material facts. Signature of life to be assured:
D D M M Y Y
1647 GPE EB PSEU App 05/15
Date:
Data Protection I undertake to disclose all material facts to Generali PanEurope dac (Generali PanEurope) for the purposes of assessing this application. Such facts are those which Generali PanEurope dac would regard as likely to influence the assessment and acceptance of a proposal. If in doubt as to the relevance of any particular information, you should disclose it as failure to do so could result in you being quoted the wrong terms, a claim being rejected or reduced or rendering the policy invalid at a later date. I also consent that my telephone calls with Generali PanEurope may be recorded for the purposes of quality control or for the purposes of confirming data. I accept and consent that Generali PanEurope may pass data originating from this application or data relating to the execution of this contract (e.g. premiums, events insured against, changes to risk or contract) to other companies of the Generali Group, Financial Advisers, Investment Advisers, Portfolio Managers, Investment Fund Providers, Fiscal Representatives, Reinsurers and other third parties for legitimate business reasons or for compliance with local or foreign regulatory requirements but only in so far as it is required to ensure the proper execution of my insurance matters. I accept that the above applies regardless of whether this contract is concluded. I also accept that personal data, however obtained, will be held, recorded and processed by Generali PanEurope dac, as data controllers, who are registered under and adhere to the Irish Data Protection Act 1988 and Data Protection (Amendment) Act 2003, as may be amended from time to time, on computers and/or manual systems in respect of my insurance dealings with Generali PanEurope dac, both now and in the future for administrative, identification, customer care, service and marketing purposes and to comply with legal obligations including but not limited to legal obligations under company law and anti-money laundering legislation and that this data will remain confidential. I accept that some of the parties to whom Generali PanEurope may disclose my information may be to countries outside of the Europe Economic Area (‘EEA’) and may not have the same data protection laws as in Ireland. Details of such countries can be provided upon request. I hereby confirm that I will inform Generali PanEurope of any changes to my personal information so that the information held by Generali PanEurope is accurate and up to date. I understand that I have the right to obtain access to and request correction of any personal information concerning me held by Generali PanEurope. Requests for such access or any other requests in relation to data protection can be made to the Data Protection Officer, Generali PanEurope dac, Generali House, Navan Business Park, Athlumney, Navan, Co. Meath C15 CCW8, Ireland.
Note: Please sign and return completed form to Lyons Financial Services, Office 1, Dunboyne Business Park, Dunboyne, Co. Meath, Ireland. Signature of life to be assured:
Date:
D D M M Y Y
Salary Deduction Mandate for PSEU Income Protection Plan Full name: Staff number:
Office telephone number:
Name and address of employer
Signature: Date:
D D M M Y Y
1647 GPE EB PSEU App 05/15
I accept the deduction of a percentage of my salary to cover the cost of my inclusion in the Income Protection Plan. I accept that this deduction, being made solely as a measure of convenience to me, may be terminated at any time. I also accept that the ultimate responsibility for ensuring that the deduction has in fact been made from my salary rests with me and that beyond making appropriate remittances direct to Generali PanEurope and/or Lyons Financial Services, in accordance with the arrangements approved, the employer accepts no responsibility of any kind in the matter.
Lyons Financial Services Office 1, Dunboyne Business Park, Dunboyne, Co. Meath, Ireland.
Generali PanEurope dac
Tel: +353 (0)1 801 5808 Fax: (0)1 825 1183
Tel: +353 (0)46 909 9760 Fax: +353 (0)46 909 9849
Email:
[email protected]
Email:
[email protected]
Generali House, Navan Business Park, Athlumney, Navan, Co. Meath C15 CCW8, Ireland.
Roisin Lyons t/a Lyons Financial Services is regulated by the Central Bank of Ireland. Generali PanEurope dac is regulated by the Central Bank of Ireland. Generali PanEurope dac is a designated activity company registered in Ireland (Number 311420) with a registered office at Generali House, Navan Business Park, Athlumney, Navan, Co. Meath C15 CCW8, Ireland. Generali PanEurope dac is part of the Generali Group. The Generali Group has a listed number in the Italian Insurance Group Register of 026.
